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Vital Signs

Vital Signs. Assessment of Vital Signs. Temperature Pulse Respirations Blood Pressure The fifth vital sign Pain Oxygen Saturation. Temperature. Regulation hypothalamus Core body temperature Set point. Heat Production. Metabolism Shivering Exercise. Radiation

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Vital Signs

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  1. Vital Signs

  2. Assessment of Vital Signs • Temperature • Pulse • Respirations • Blood Pressure • The fifth vital sign • Pain • Oxygen Saturation

  3. Temperature • Regulation • hypothalamus • Core body temperature • Set point

  4. Heat Production • Metabolism • Shivering • Exercise

  5. Radiation transfer from surface Conduction transfer through direct contact Convection transfer by air movement Evaporation transfer when liquid changed to a gas Heat Loss

  6. 97 - 100 F (98.6) 36 - 39 C (37) must be able to close mouth eating or smoking, wait Contraindications unconscious seizures infants, young children oral disease/surgery mouth breathing oxygen by mask Oral Temperature

  7. Reliable Higher than oral by 1o Contraindications rectal surgery diarrhea rectal disease heart disease Rectal Temperature

  8. Other Methods • Axillary • used when oral or rectal contraindicated • lower than oral by 1o • Tympanic membrane • readily accessible • not affected by eating, smoking, cerumen

  9. Elevated Temperature • Pyrexia • Hyperpyrexia

  10. Signs and Symptoms shivering blood vessels constrict absence of sweating Care assessment blankets fluids nourishment Oxygen Chill Phase

  11. Temp at new set point Signs and Symptoms flushed skin warm skin weak, muscle aches drowsy, restless Care Comfort Hydration Prevent shivering Limit physical activity Oral hygiene Environmental temperature control Fever Phase

  12. Signs and Symptoms profuse diaphoresis less shivering flushed, warm skin Care fluids light clothing hypothermia blanket Medications Oral hygiene Environmental temperature control Flush or Crisis Phase

  13. Subnormal Temperature • Hypothermia • Chemical reactions slowed • Metabolic demands for oxygen decreased

  14. Assessing Temperature • Glass thermometers • oral = blue, thin bulb • rectal = red, blunt tip • Electronic • oral = blue • rectal = red • Temperature sensitive patches

  15. Pulse • Rate • pulsations per minute • Infant normal = 80 - 180 per minute • Adult normal = 60 - 100 per minute • Slow < 60, bradycardia • Fast > 100, tachycardia • Slowest at rest, early morning

  16. pain stress fear anger anxiety exercise decrease BP temp low oxygen medications Tachycardia

  17. Pulse Rhythm • Pattern of pulsations • Regular • Irregular • dysrhythmia • arrhythmia

  18. Pulse Quality or Amplitude • Description of fullness of pulse • Ratings • 0 = Absent • +1 = thready, weak • +2 = normal • +3 = bounding

  19. carotid brachial radial femoral popliteal posterior tibial dorsal pedis apical 5th ICS left use stethoscope Assessment Sites

  20. Apical - Radial Pulse • 2 nurses • count at same time • differences found with irregular pulses

  21. Respiration • Movement of air in and out of lungs • Regulation • carbon dioxide levels • oxygen levels • Normal adult rate: 12 to 20 per minute • Infant rate 30 - 80 per minute

  22. rate: illness, fever acute pain stress exercise altitude body position rate narcotics CNS depressants Deviations From Normal

  23. Apnea Dyspnea Orthopnea Tachypnea Bradypnea Cheyne - Stokes Respiratory Terms

  24. Blood Pressure • Force of blood against vessel walls • Systolic pressure • Diastolic pressure • Pulse pressure

  25. Factors to Maintain BP • Peripheral Resistance • Pumping action of the heart • Blood volume • Viscosity of the blood • Elasticity of vessel walls

  26. Factors Affecting BP • Age • Time of day • Gender • Eating • Exercise • Emotions • Position • Activity • Smoking/drinking

  27. Classification of Blood Pressure for Adults

  28. Hypotension • Usually considered less than 90 systolic • The patient’s tolerance is significant in determining the diagnosis • Orthostatic or postural hypotension

  29. Proper Measurement • Correct position • arm at heart level • Arm above heart level - low reading • Arm below heart level - high reading • Korotkoff Sounds • first sound = systolic • absence of sounds = diastolic • Auscultatory gap

  30. Proper Measurement • Cuff Size • too large - low reading • too small - high reading • Bladder width 40% of limb circumference • Bladder length 80% of limb circumference

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